Guidelines for Treatment of Urinary Tract Infections (UTIs ...

Guidelines for Treatment of Urinary Tract Infections (UTIs) in Adults ¨C January 2018

Infection

Antimicrobial

Duration

Comments

Therapy¡ì

Asymptomatic

Bacteriuria

When to order a

Urinalysis or Urine

Culture

Recommendations

for when to order a

urinalysis or urine

culture based on

Signs/Symptoms of

a UTI

National guidelines recommend against testing for asymptomatic bacteriuria except in select circumstances

(pregnancy, prior to urologic procedures)

?

?

?

?

?

?

?

?

Fever >38??C or rigors without alternative cause

Do not send urine culture if

Urgency, frequency, dysuria

none of these symptoms are

Suprapubic pain or tenderness

present or there is an

Costovertebral pain or tenderness

alternative cause

New onset mental status changes without

No Antibiotic Treatment for ASB

alternative cause

Recommendation

in the absence of signs or

Acute hematuria

symptoms attributable to a urinary tract

Spinal cord injury spasticity or autonomic dysreflexia

infection, patients with a positive urine culture

> 2 SIRS criteria (T > 38 C or < 35 C, HR > 90, RR >20 or PaCO212 K/mm3 or 10%

pyuria should not be treated with

bands) OR shock with concerns for sepsis

antibiotics

irrespective of high bacterial colony count, or a

In the absence of signs or symptoms* (see above) attributable to a urinary

tract infection,

with a positive

multi-drug

resistantpatients

organism

urine culture should not be treated with antibiotics irrespective of whether there is pyuria, high bacterial colony

count, or a multi-drug resistant organism. Exceptions to this recommendation include pregnant patients and

patients with asymptomatic bacteriuria prior to a urologic procedure.

Uncomplicated

Lower Tract

Infections or

Cystitis

?

?

females without

catheters

females without

co-morbid

conditions listed

under

complicated

UTIs

Trimethoprim-Sulfamethoxazole1

PO

Nitrofurantoin

Alternatives

Fosfomycin1*

Cephalexin1 (or other oral ¦Âlactam)

3 days

?

5 days

?

1 dose

3-7 days

?

?

Treatment of Uncomplicated Lower

UTI or Cystitis

HMS recommendation of antibiotic

treatment and duration

?

Empiric antibiotic choice should take into

consideration recent previous culture

results, prior antibiotic use, antibiotic

allergies, and severity of presenting illness

Fluoroquinolones should be used for only

when other oral antibiotic options are not

feasible because of their propensity for

collateral damage (antibiotic resistance,

C.difficile infection, and other adverse

effects). When a fluoroquinolone is used

for uncomplicated cystitis, the duration of

treatment is 3 days.

Nitrofurantoin should be avoided in

patients with CrCl < 30 mL/min

If susceptibility available at 48-72 hrs, deescalate treatment to susceptible narrowspectrum antibiotic

*Fosfomycin is restricted to patients with

suspected or confirmed multi-drug

resistant organisms. Susceptibilities only

established for E. coli and Enterococcus

species, but there is data and clinical

experience supporting the use of the same

susceptibility breakpoints for other

members of the Enterobacteriaceae group

¡ì Prior to confirmation of pathogen

1. Refer to SJMHS antibiotic dosing tables for dose adjustments in renal dysfunction.

References

??

Gupta K et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update from

the IDSA and ESCMID. Clin Infect Dis. 2011;52(5):e103-e120.

Hooton et al. Diagnosis, Prevention, and Treatment of Catheter Associated UTI in Adults: 2009 International Clinical Practice Guidelines from the IDSA. Clin

??

Infect Dis. 2010;50:625-663.

Nicolle LE et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis.

??

2005;40:643-54.

Reviewed/ Approved by: SJMH Antimicrobial Subcommittee: Jan 2018; SJMH P & T Committee /2018; Last updated Jan/2018

Contributors: Curtis Collins, PharmD, Anu Malani, MD

Complicated Lower

Tract Infections or

Cystitis

Treatment of

Complicated Lower

UTI without

sepsis/bacteremia

HMS

recommendation of

antibiotic treatment

and duration

Includes patients with catheter associated-urinary tract infections (CA-UTI) and patients not meeting the definition

for uncomplicated lower UTI/cystitis: Male, urinary catheter present or removal within the last 48 hrs., GU

instrumentation, anatomic abnormality or obstruction, significant co-morbidities, such as:

?

?

?

?

?

?

?

Nephrolithiasis

Urolologic surgery

Urinary obstruction

Urinary retention

Spinal cord injury

Asplenia

Receiving chemotherapy for a

malignancy or malignancy not

in remission

Trimethoprim-Sulfamethoxazole1

PO

Nitrofurantoin

Fosfomycin1*

Cephalexin1

IV Ceftriaxone OR IV ¦Â-lactam

followed by other oral agent

?

?

?

?

?

Moderate/seve

re liver disease

Hemiplegia

CHF

Cardiomyopathy

Moderate/severe

CKD or on HD

?

?

?

?

?

?

7 days

?

7 days

Q 48 h X 3 doses

7 days

< 7 days

?

?

?

?

?

Treatment of Uncomplicated Pyelonephritis

HMS recommendation of antibiotic treatment and

duration

Pyelonephritis and

Urinary Tract

Infections

Associated with

Bacteremia

Sickle cell disease

Chronic anti-coagulation

Bedridden or using a wheelchair

Diabetes mellitus with Hgb A1C>8%

Immunodeficiency or immunosuppressive

treatments

Structural lung disease (moderate-severe

COPD, bronchiectasis, home oxygen)

Empiric antibiotic choice should take into

consideration recent previous culture results,

prior antibiotic use, antibiotic allergies, and

severity of presenting illness

Final choice depends upon confirmation of

specific pathogen, the susceptibility pattern,

and patient allergies

Nitrofurantoin should be avoided in patients

with CrCl < 30 mL/min

A 3-dose fosfomycin treatment course can be

used for women < 65 years who develop a CAUTI without upper tract symptoms after the

indwelling catheter has been removed

Fluoroquinolones should be used for only when

other oral antibiotic options are not feasible

because of their propensity for collateral

damage (antibiotic resistance, C.difficile

infection, and other adverse effects). When a

fluoroquinolone is used for complicated lower

UTIs, the duration of treatment is 7 days.

*Fosfomycin is restricted to patients with

suspected or confirmed multi-drug resistant

organisms. Susceptibilities only established for

E. coli and Enterococcus species, but there is

data and clinical experience supporting the use

of the same susceptibility breakpoints for other

members of the Enterobacteriaceae group

Uncomplicated Pyelonephritis: female pts without catheters or any of the co-morbid conditions listed in the

definition for complicated lower UTI

Complicated Pyelonephritis: patients with pyelonephritis not meeting definition for uncomplicated pyelonephritis

Uncomplicated Pyelonephritis

Trimethoprim-Sulfamethoxazole1

?

Empiric antibiotic choice should take into

7-14 days

¡ì Prior to confirmation of pathogen

1. Refer to SJMHS antibiotic dosing tables for dose adjustments in renal dysfunction.

References

??

Gupta K et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update from

the IDSA and ESCMID. Clin Infect Dis. 2011;52(5):e103-e120.

Hooton et al. Diagnosis, Prevention, and Treatment of Catheter Associated UTI in Adults: 2009 International Clinical Practice Guidelines from the IDSA. Clin

??

Infect Dis. 2010;50:625-663.

Nicolle LE et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis.

??

2005;40:643-54.

Reviewed/ Approved by: SJMH Antimicrobial Subcommittee: Jan 2018; SJMH P & T Committee /2018; Last updated Jan/2018

Contributors: Curtis Collins, PharmD, Anu Malani, MD

Treatment of

Uncomplicated

Pyelonephritis

HMS

recommendation

for antibiotic

treatment and

duration

Treatment of

Complicated

Pyelonephritis and

UTI with Bacteremia

HMS

recommendation

for antibiotic

treatment and

duration

PO

Fluoroquinolones1

¦Â-lactams (Ceftriaxone)

Complicated Pyelonephritis and

UTI with Bacteremia

Complicated Pyelonephritis

¦Â-lactams (Ceftriaxone or

cefepime1; may be followed by oral

antibiotic therapy)

UTI with Bacteremia**

¦Â-lactams (Ceftriaxone or

cefepime1)

5-7 days

IV therapy: 7 days

IV to PO ¦Âlactam/other

susceptible PO

agent: 7-14 days

(combined IV+PO)

7-14 days

?

?

?

7-14 days

Shorter courses of

therapy (7-days)

with a

fluoroquinolone or

IV ¦Â-lactam can be

considered in female

patients without comorbid conditions

who are bacteremic

secondary to

pyelonephritis or

cystitis/lower UTI

who have rapid

clinical response

?

consideration recent previous culture results,

prior antibiotic use, antibiotic allergies, and

severity of presenting illness

Final antibiotic choice should be based on

antibiotic susceptibilities of the pathogen and

take into consideration antibiotic allergies of

the patient

Nitrofurantoin and fosfomycin should not be

used for pyelonephritis, upper urinary tract

infection, or patients with bacteremia

Oral ¦Â-lactams are associated with lower

efficacy and higher relapse rates compared to

trimethoprim-sulfamethoxazole and

fluoroquinolones. If a ¦Â-lactam is used then

initial therapy should be IV therapy followed

by oral ¦Â-lactam (assuming uropathogen is

susceptible)

**Due to potential complications from PICC

lines (e.g. DVT, CLABSI), oral

fluoroquinolones are preferred over PICC line

placement for IV antibiotics when the urinary

pathogen is susceptible and there are no

contraindications to fluoroquinolones.

¡ì Prior to confirmation of pathogen

1. Refer to SJMHS antibiotic dosing tables for dose adjustments in renal dysfunction.

References

??

Gupta K et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update from

the IDSA and ESCMID. Clin Infect Dis. 2011;52(5):e103-e120.

Hooton et al. Diagnosis, Prevention, and Treatment of Catheter Associated UTI in Adults: 2009 International Clinical Practice Guidelines from the IDSA. Clin

??

Infect Dis. 2010;50:625-663.

Nicolle LE et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis.

??

2005;40:643-54.

Reviewed/ Approved by: SJMH Antimicrobial Subcommittee: Jan 2018; SJMH P & T Committee /2018; Last updated Jan/2018

Contributors: Curtis Collins, PharmD, Anu Malani, MD

Guidelines for Treatment of Urinary Tract Infections (UTIs) in Adults Dosing Recommendations

Antibiotic

Dose*

Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1

1

Nitrofurantoin

Fosfomycin

1 DS tablet po BID

100 mg po BID

3 g dose (see tables for complicated and uncomplicated lower UTI)

Amoxicillin-clavulanate1

875mg po BID

Uncomplicated Cystitis: 500 mg po BID

500 mg po BID-QID

Cephalexin1

Uncomplicated Cystitis: 500 mg po BID

100-200 mg po BID

Cefpodoxime1

Uncomplicated Cystitis: 100 mg po BID

1-2g IV q 8 hr

Cefazolin1

1

500 mg po BID

Cefuroxime *

750 mg-1.5g IV q 8 hr

Uncomplicated Cystitis: 250 mg po BID

3.375 g IV q 6 hr or 4.5 g IV q 6-8 hr

Piperacillin-tazobactam1

Ceftriaxone

1-2 g IV once daily

1-2 g IV q 8-12 hr

Cefepime1

250-750 mg QD

Levofloxacin1

Uncomplicated Cystitis: 250 mg po QD

Uncomplicated Pyelonephritis:

7-day duration: 500 mg po QD

5-day duration: 750 mg po QD

250-750 mg po BID

Ciprofloxacin1

400 mg IV q12 hr

Uncomplicated Cystitis: 250 mg po BID

Uncomplicated Pyelonephritis: 500 mg po BID

* Dose depends on disease state (Uncomplicated UTI, Complicated UTI, Pyelonephritis), severity of presentation (e.g. septic shock, severe

sepsis), presence of bacteremia, and susceptibilities of the pathogen

¡ì Prior to confirmation of pathogen

1. Refer to SJMHS antibiotic dosing tables for dose adjustments in renal dysfunction.

References

??

Gupta K et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update from

the IDSA and ESCMID. Clin Infect Dis. 2011;52(5):e103-e120.

Hooton et al. Diagnosis, Prevention, and Treatment of Catheter Associated UTI in Adults: 2009 International Clinical Practice Guidelines from the IDSA. Clin

??

Infect Dis. 2010;50:625-663.

Nicolle LE et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis.

??

2005;40:643-54.

Reviewed/ Approved by: SJMH Antimicrobial Subcommittee: Jan 2018; SJMH P & T Committee /2018; Last updated Jan/2018

Contributors: Curtis Collins, PharmD, Anu Malani, MD

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